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The Medicare Annual Wellness Visit billing trap: what Sioux Falls patients should know for 2026

Medicare's yearly wellness visit is free by federal rule. One extra sentence at the front desk can quietly turn it into two bills.

Big Sioux Benefits Data Desk

Published August 12, 2026 · 12 min read · Sourced from CMS.gov and Medicare.gov

Medicare's Annual Wellness Visit is a genuine $0 benefit — no deductible, no coinsurance, guaranteed by federal rule. The bill some people get afterward isn't a mistake or a scam; it's a second, separate visit code added the moment a new health problem gets discussed at the same appointment. That distinction is buried in Medicare paperwork most people never read closely, which is exactly why it keeps catching people off guard in Sioux Falls and everywhere else.

Here's the pattern, in plain terms: you book what you're told is your "free annual checkup." You show up, and along with the routine questions about your history and your medications, you mention that your knee has been bothering you, or you ask the doctor to take a look at a mole, or you request a refill that needs a real medical decision behind it. Two or three weeks later, a Medicare Summary Notice or a bill from the clinic arrives with a charge on it you didn't expect. Nobody at the front desk lied to you — the wellness visit really was free — but nobody flagged, in the moment, that the conversation had quietly crossed into a second, billable service. That gap between what gets said out loud and what gets billed is the whole story of this guide.

Every figure in this guide comes from a source fetched and confirmed this week: Medicare.gov's Yearly Wellness Visit page, CMS's 2026 Parts A & B premiums and deductibles fact sheet, the CMS Medicare Learning Network's Annual Wellness Visit compliance page, and billing guidance from the American Medical Association and the American Academy of Family Physicians. No invented numbers, nothing pulled from memory.

What the Annual Wellness Visit actually is

The Annual Wellness Visit (AWV) is a Medicare Part B preventive benefit built around a conversation, not an exam. Medicare.gov describes it plainly: it's "not a routine physical exam." Instead, it covers a review of your medical and family history, routine measurements like blood pressure and weight, a cognitive screening for signs of dementia, and a written, personalized prevention plan for the year ahead. It is explicitly free — the Part B deductible does not apply, and you owe no coinsurance if your provider accepts assignment, according to Medicare.gov.

There's a related benefit that trips people up: the Initial Preventive Physical Exam (IPPE), nicknamed the "Welcome to Medicare" visit. That's a separate, one-time visit available only in your first 12 months of Part B coverage. After that window closes, your yearly benefit is the AWV — billed with code G0438 the first time and G0439 every year after, per CMS's Medicare Learning Network. G0438 is a lifetime, one-time code; billing it twice for the same person is flagged and denied under CMS's Recovery Audit Program rules.

Why a second bill shows up

The short version: Medicare allows your doctor to bill two things on the same day if two different things actually happened. The Annual Wellness Visit covers prevention. If you also bring up a new symptom — a knee that's been bothering you, a rash, chest tightness, a request to adjust a blood pressure medication — and your provider does the work to evaluate it, that's a second, medically necessary service. The American Medical Association confirms physicians are "not prohibited" from billing both on the same visit, provided the extra work is "significant and separately identifiable" from the preventive checklist.

This isn't an edge case. It's common enough that CMS built a specific billing code just for it, and common enough that both major physician trade groups publish guidance telling doctors' offices exactly how to do it correctly.

The modifier 25 mechanic, in plain terms

When that happens, the office adds modifier 25 to a separate office-visit code — typically something in the 99202-99215 range — attached to your wellness-visit claim. The American Academy of Family Physicians describes the standard: the added work has to be "above and beyond the usual work" of the preventive visit, and it has to be documented well enough to show it was a real, separate evaluation, not a formality. Since January 1, 2025, Medicare has also allowed an add-on code, G2211, when that same-day E/M service is billed with modifier 25 — a further sign this is a well-established, deliberate part of how Medicare billing works, not a loophole.

The AAFP is direct about the consequence for your wallet: "preventive and wellness services are not subject to cost-sharing, [but] the office/outpatient E/M service may be subject to deductible and cost-sharing." That's the whole trap in one sentence — one visit, two codes, and only one of them is free.

Walk through what that looks like in practice, without inventing dollar figures we can't verify: say you go in for your AWV, and partway through you mention your knee has been aching for a month. If your doctor examines the knee, discusses treatment options, and documents that work as a distinct medical decision, that portion can be billed as an office visit — coded 99202 through 99215 depending on complexity — with modifier 25 attached. If you haven't yet met your 2026 Part B deductible of $283, that added visit counts toward it. Once you've met the deductible for the year, you owe 20% coinsurance on the Medicare-approved amount for that visit, same as any other Part B service. The wellness-visit portion, on the same claim, stays at $0 the entire time. Two codes, two outcomes, one appointment.

The numbers behind the confusion

This isn't just a communication gap between doctor and patient — CMS's own audit data shows the billing itself is genuinely hard to get right. According to the CMS Medicare Learning Network's compliance tips page, the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data found a 24.5% improper payment rate on Annual Wellness Visit claims (including subsequent visits billed as G0439), projecting $307.5 million in overpayments nationwide. That's not evidence of a scam aimed at patients — it's evidence that both sides of the appointment, biller and patient, are navigating a genuinely confusing rule.

The 2026 cost-sharing figures for context, all from CMS's Parts A & B premiums and deductibles fact sheet released November 14, 2025: the standard Part B monthly premium is $202.90, the Part B annual deductible is $283, the Part A inpatient hospital deductible is $1,736, and skilled nursing facility coinsurance for days 21-100 is $217 a day. None of that applies to your wellness visit itself — it's the backdrop for what the added visit can cost once your deductible is in play.

What's covered at $0, and what isn't

The cleanest way to keep the line clear is to know the actual checklist. Everything below is a $0 part of the Annual Wellness Visit under federal rule — no deductible, no coinsurance, per Medicare.gov and CMS's Medicare Learning Network:

Source: Medicare.gov, Yearly Wellness Visits and CMS MLN Compliance Tips: Annual Wellness Visits. 2026 cost-sharing figures per CMS, November 14, 2025.

It also helps to see how the Annual Wellness Visit sits next to the two other exams people tend to confuse it with — the one-time "Welcome to Medicare" exam, and the routine physical most people had every year before they went on Medicare:

Source: CMS Medicare Learning Network, Annual Wellness Visits compliance page.

Notice what's missing from all three rows: a hands-on physical exam is not part of any of Medicare's standard preventive visits. That's the single most common source of the surprise. People expect the exam their old employer plan covered every year — stethoscope, reflexes, the works — and Medicare's free visit was simply never built to be that.

The Sioux Falls picture

Minnehaha County has 39,532 Medicare beneficiaries, per CMS county enrollment data, and CDC's local health survey found 76.6% of Minnehaha County adults had a routine checkup in the past year. That leaves close to a quarter who didn't — some of them likely avoiding the appointment over exactly this kind of billing confusion, even though the wellness visit itself costs nothing.

Sioux Falls care runs through two systems, Sanford and Avera, and the billing mechanics described above apply at both — modifier 25 is a Medicare rule, not a hospital-system policy. CMS's Hospital Compare rates Sanford USD Medical Center at 5 stars and Avera McKennan Hospital & University Health Center at 4 stars, and whichever system your primary care clinic sits inside, the same AWV-versus-E/M distinction governs your bill.

Your Medicare coverage type matters here too. Minnehaha County's 5 standard Medicare Advantage PPOs, open to anyone with Medicare in the county, are shown below with their current premiums and CMS star ratings:

Source: CMS Medicare Advantage / Part D Landscape (PY2026) & CMS Medicare Advantage & Part D Star Ratings (2026), Minnehaha County, plan year 2026.

Whether you're on Original Medicare or one of these Medicare Advantage plans, the wellness-visit rule is federal, not plan-specific — the visit is free either way. What changes is what you owe if a second, billed visit gets added: Original Medicare charges the 20% Part B coinsurance described above, while a Medicare Advantage plan applies its own office-visit copay instead. Big Sioux Benefits compares the plans we offer in the Sioux Falls area against your doctors and your actual costs, including how each one handles a same-day office visit.

How Medigap changes the math

If you carry Original Medicare plus a Medicare Supplement (Medigap) policy, the added office-visit charge doesn't disappear — but who pays it shifts. Medigap Plan G, the most comprehensive option available to anyone newly eligible for Medicare since January 1, 2020, covers your Part B coinsurance in full, per the CMS-standardized plan matrix. That means the 20% you'd otherwise owe on the billed portion of your wellness visit gets picked up by the supplement instead of coming out of your pocket, once your Part B deductible is met. Plan N covers the same coinsurance but carves out a small copay — up to $20 for an office visit — for exactly this kind of scenario.

Source: CMS Publication 02110, Choosing a Medigap Policy, standardized plan benefits under 42 CFR §403.205.

Neither Medigap plan touches the Part B deductible itself — you still owe the first $283 of Part B costs in 2026 before either plan's coinsurance coverage kicks in. But once that's met, the difference between having a Medigap policy and not having one, on exactly this kind of surprise second bill, is real money.

Local chronic-condition rates help explain why this matters here specifically — a wellness visit that turns into "let's also talk about your blood pressure" is common when the underlying numbers look like this:

Source: CDC PLACES: Local Data for Better Health, County 2023 (2023), adults in Minnehaha County.

None of that is a reason to avoid raising a real concern at your wellness visit — it's a reason to walk in knowing that raising it may add a second, billed code to an otherwise free appointment.

How to keep your visit free

You don't need anyone's help to do this, and you don't need to change doctors, avoid mentioning symptoms, or become an expert in billing codes. The whole method is three habits, and all three are free. None of them require confrontation — they're just the specific words that tell a busy front desk which visit you're there for, before the appointment starts, not after the claim is already filed.

What to do if you already got the bill

If a bill already arrived and you're not sure it's right, start with your Medicare Summary Notice (Original Medicare) or your plan's Explanation of Benefits (Medicare Advantage). Both documents list every code billed against every visit, in plain enough language that you can match dates to charges. Look for the wellness-visit code — G0438 or G0439 — sitting next to a second code in the 99202-99215 range with modifier 25 attached. If both are there, the billing likely followed the rule described above, even if it wasn't explained to you at the time.

It's worth saying plainly: most of these bills are correct. The point of this guide isn't to teach you to dispute a legitimate charge — it's to help you recognize the difference between a real billing error and a normal, documented consequence of a productive conversation with your doctor. Both are common. Only one of them is worth pushing back on.

1. Call the billing office first. Ask what modifier 25 covered on your specific visit. Most disputes get sorted out here, in one call.
2. Compare it to your visit. Did you raise a new symptom, ask for a refill that needed review, or get a hands-on exam of a specific problem? If none of that happened, say so — that's a legitimate basis to question the charge.
3. Request an itemized statement if the explanation doesn't add up. You're entitled to see exactly what was billed and why.
4. File a formal appeal if the office can't resolve it. Original Medicare and Medicare Advantage each have a defined appeals process with real deadlines.

You don't have to do this alone. Most people find the paperwork is the part they'd rather have a second pair of eyes on — book a conversation and we'll go through the notice with you, no cost, no obligation.

Medicare Advantage and the wellness visit

Medicare Advantage plans are required to cover the same preventive benefits Original Medicare covers, generally at no cost when you use an in-network provider — the Annual Wellness Visit is one of them. The billing mechanics for an added problem-focused visit follow the same underlying idea (a second, separately identifiable service), but the dollar amount you owe depends on your specific plan's office-visit copay rather than the flat 20% Part B coinsurance. That's one more reason your plan's Evidence of Coverage, not a general rule of thumb, is the document that actually answers "what will this cost me."

If you'd rather have someone local walk through your specific plan's cost-sharing with you, that's what we're here for — book a conversation, no rush and no cost to talk.

What to watch as you book your next wellness visit

1. Book it as an "Annual Wellness Visit," by name — not a "checkup" or "physical."
2. Ask at check-in whether anything beyond the standard checklist is likely to be billed that day.
3. Save new symptoms for a second appointment if you want to be certain the wellness visit itself stays at $0.
4. Read your Medicare Summary Notice or EOB line by line after the visit — the codes tell the real story.
5. Keep an eye on your 2026 Part B deductible ($283) — that's what applies to any added, billed visit, not the wellness visit itself.

How we know all this: Big Sioux Benefits runs every article through a data desk that cross-references CMS's own Medicare Learning Network compliance data, the 2026 CMS Parts A & B cost-sharing fact sheet, the Minnehaha County Medicare Advantage plan landscape, CMS Hospital Compare, CDC PLACES local health data, and current AMA/AAFP physician billing guidance — built by Strategic AI Architects. Every figure here is sourced and dated. This is education, not medical or legal advice; confirm your specific bill with your provider's billing office or Medicare.gov, and confirm plan details with a licensed agent. We take no payment from any carrier to feature a plan, and Big Sioux Benefits is a licensed independent insurance agency, not connected with or endorsed by the United States government or the federal Medicare program.